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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803698
Report Date: 01/30/2025
Date Signed: 01/30/2025 03:24:44 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/05/2024 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20241205144452
FACILITY NAME:VINEYARD AT FOUNTAINGROVE, THEFACILITY NUMBER:
496803698
ADMINISTRATOR:SANDHU,RAJVIRFACILITY TYPE:
740
ADDRESS:200 FOUNTAINGROVE PKWYTELEPHONE:
(707) 544-4909
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:64CENSUS: 25DATE:
01/30/2025
UNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Denise Downey (Executive Director)TIME COMPLETED:
03:39 PM
ALLEGATION(S):
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-Staff do not ensure residents receive bathing service in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Cuadra and Deniz arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Denise Downey, Executive Director.

Another allegation of staff does not ensure residents receive bathing service in a timely manner. According to complainant residents are not getting their showers done regularly due to lack of staffing. Per co-complainant, R2 had been observed without underwear multiple times and found that R2 is often not bathed. Based on records review, the facility provided with activities of daily living (ADL) assistance notes for the month of October 2024 for 12 out of 26 residents indicates that residents had not been assisted with bathing regularly according to their care plans. Based on interviews conducted with staff (S5, S6, S7, S8 & S9), revealed that they struggle to assist residents with their “scheduled” shower dates due to lack of staffing, because when they reach out to management, they get minimum help leading them to rely on floating staff member or any med-technician to ask them for help.
Continued on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 21-AS-20241205144452
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: VINEYARD AT FOUNTAINGROVE, THE
FACILITY NUMBER: 496803698
VISIT DATE: 01/30/2025
NARRATIVE
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Continued from LIC9099...

Some staff do not recall if there is an existing “shower schedule” for residents. Per staff, there are times when family members approach them asking for assistance, because they have found their loved one needing help, but it is hard to assist them all of them with the number of staff present at the facility. According to staff, the management team don't listen to staff covering needs. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given. Failure to correct the deficiencies may result in civil penalties. The Department will review information obtained to determine if further actions are needed.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 21-AS-20241205144452
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: VINEYARD AT FOUNTAINGROVE, THE
FACILITY NUMBER: 496803698
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/31/2025
Section Cited
CCR
87464(f)(4)
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87464 Basic Services (f) Basic services shall at a minimum include: (4) Personal assistance & care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as…bathing…This requirement has not been met as evidence by:
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The facility will submit an updated schedule reflecting staff coverage at all times to meet resident’s needs as stated per regulation by POC due date to clear the deficiency.

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Based on record review and interviews, facility records of ADLs documented for the month of October 2024, there are 12 out of 26 residents who do not have received baths as agreed on their admission agreements, which poses an immediate risk to the health and safety of the residents.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/05/2024 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20241205144452

FACILITY NAME:VINEYARD AT FOUNTAINGROVE, THEFACILITY NUMBER:
496803698
ADMINISTRATOR:SANDHU,RAJVIRFACILITY TYPE:
740
ADDRESS:200 FOUNTAINGROVE PKWYTELEPHONE:
(707) 544-4909
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:64CENSUS: 25DATE:
01/30/2025
UNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Denise Downey (Executive Director)TIME COMPLETED:
03:39 PM
ALLEGATION(S):
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-Staff do not ensure medications are dispensed as prescribed to residents in care.
-Staff do not ensure resident records are accurately maintained.
-Staff do not ensure residents are provided with clean clothing.
-Residents developed pressure injuries while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Cuadra and Deniz arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Denise Downey (Executive Director).

The Department received an allegation of staff do not ensure medications are dispensed as prescribed to residents in care. Per complainant, the facility has several medication errors like medication not being dispensed to the correct residents. According to the complainant one of the MedTech staff (S1) gave a resident (R1) a double dose of morphine by mistake because they forgot that staff already dispensed it to the resident. There is also a co-complainant who states that at times they have observed only one MedTech on site. Per co-complainant, on 12/12/24 they have found one pink pill on the floor of resident’s (R2) room, then on 12/21/24 they found another pink pill on the floor and there were only two staff at the facility. Also, on 12/23/24 they found two medications on the floor at the same resident’s room. Based on confidential interviews with staff (S3) confirmed the incident of the morphine was off during crossover process between incoming and outgoing med-technicians. Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 21-AS-20241205144452
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: VINEYARD AT FOUNTAINGROVE, THE
FACILITY NUMBER: 496803698
VISIT DATE: 01/30/2025
NARRATIVE
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Continued from LIC9099A...
The narcotic count revealed that there was a discrepancy of morphine dosage for R1, S3 noticed that an empty syringe was placed between the full ones, S3 refused to sign off their name, documented the discrepancy, but upon the mistake was identified, health service director removed the syringe. However, it is unclear if R1 was provided with an extra morphine dosage by accident or not. LPA conducted 10-day visit on 12/09/24 performed a spot check of medications of residents (R1 and R2) did not reveal any inconsistency with medication management. Although, the facility did not have any documentation of this incident, the facility has been cited previously on another complaints #21-AS-20240516095437 due to mishandling medications. Regarding medication found on the floor, LPA conducted interviews with staff (S3 & S4) were unable to provide any supporting evidence that any pill has been found on the floor of a resident’s room. Due to very limited information obtained from interviews and records review, LPA is unable to determine if alleged allegation have happened at prior date to prove or disprove the above allegation. A finding that the complaint allegation occurs of staff do not ensure medications are dispensed as prescribed to residents in care is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Regarding allegation of staff do not ensure resident records are accurately maintained. Per Reporting party, there was an incident where the MedTech staff (S1) gave a resident (R1) a double dose of morphine by mistake. Upon discover of the error the health director (S2) destroyed the log sheet that showed the medication was given twice to the resident. At times, it had been noticed by the reporting party that there are no MedTech on site and that causes residents to not receive their medications in a timely manner, so then when the MedTech comes on shift they will give residents all their medications that were missed all at once with the help of S2 who gets on the computerized MAR sheet system to adjust the times that medications are being dispensed. Co-complainant alleges that on specific day, R2 had a fall, but staff was contacting R2’s responsible party multiple times providing different information about the reasons of R2’s hospitalization, possible due to the lack of staffing. LPA conducted 10-day visit on 12/09/24 performed a spot check of medications of residents (R1 and R2) did not reveal any inconsistency with medication records. Based on records review, the facility provided S2 termination letter due to unrelated reasons to this allegation and LPA was unable to contact S2. Incident report logs confirmed that the incident regarding R2’s witnessed fall and hospitalization have occurred. Also, the facility provided med-technician’s timesheets for the month of November 2024 that confirmed that there is one night staff who had been working overtime due to lack of staffing. However, based on interviews conducted with med-technicians, LPA did not receive any supporting evidence that medication records have not been accurately maintained by staff. Continued from LIC9099A...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 21-AS-20241205144452
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: VINEYARD AT FOUNTAINGROVE, THE
FACILITY NUMBER: 496803698
VISIT DATE: 01/30/2025
NARRATIVE
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Continued from LIC9099C...
Although, LPA is addressing personnel requirements due to lack of staff on complaint # 21-AS-20241118135715. A finding that the complaint allegation occurs of staff do not ensure resident records are accurately maintained is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Staff do not ensure residents are provided with clean clothing. Per complainant, residents’ laundry is not getting done either causing residents to have to wear the same dirty clothing. Based on records review, the facility provided housekeeping schedules for the month of November 2024 and care plans of residents indicating dressing needs been met. According to interviews conducted by LPA with staff (S5, S6, S7, S8 & S9), the process around assisting residents with their clothing consists in helping or encourage them to change their clothing daily. If they refuse to change their clothing the instruction is to try a change of face by sending another staff to change them, but if they still refuse, then the med-technicians will be notified, and the refusal will be documented for them to contact their responsible parties to notify them about it. Staff also revealed that at times they don’t have enough adult depends on hand and family members will bring them. Based on records review, the facility provided with activities of daily living (ADL) assistance notes for the month of October 2024 for 12 out of 26 residents indicates that residents had been assisted with dressing regularly according to their care plans. Refusals from residents were also confirmed as documented on daily charting notes for the month of October 2024. LPA was unable to determine if any issues could have happened at a prior date. A finding that the complaint allegation occurs of staff do not ensure residents are provided with clean clothing is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Residents developed pressure injuries while in care. Per reporting party, residents who are bedridden are getting pressure sores from not getting repositioned (level of pressure sores unknown) due to the facility not having sufficient staffing. Based on interviews conducted with staff (S3, S4, S5, S6, S8, S9, S11, S12), they have experienced some challenges due to the lack of staffing to meet resident’s needs. However, based on records review of resident’s care plans and charting notes for the time frame between October 1, 2024 - October 31, 2024, for 32 residents, did not indicate that residents that were listed in the charting alert system due to any skin issues including redness or sores were not assisted by staff with reposition and monitoring without any further skin issues found. A finding that the complaint allegation occurs of resident developed pressure injuries while in care is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6